Getting the best out of case reports in the Final year

1
Getting the best out of case reports in the Final
year

• Professor R D Griffiths,
• Professor of Medicine (Critical Care)
• Director of Final Year
• ( Acting Head of School of Medical Education)

2
Requirements

• 18 Completed clinical cases or other reports per
  attachment
• Must include at least two clinical
  science/therapeutic reports (but can be more)
• For COMP will also include 1 communication case
  study to replace a clinical case report
• 2 Adverse event/critical incident reports per
  attachment

3
Why bother with these cases?

• Absolute course requirement
• Highly praised by external examiners
• Case based learning
• Application of knowledge with reflection
• Very efficient, proven and practical way to learn
• In correct context and in retrievable form
• Gives learner responsibility to reflect
  question
• What they know they know
• How they do things
• How they behave
• Critical self-awareness is key to fitness to
  practice

4
Clinical case reports

• Collect information
• Summarise Key features of history and examination
• Analyse
• Problem list/differential diagnoses, working
  diagnosis
• Investigations results that discriminate or
  guide
• Rationalise
• Treatment plan, prescribing, advice, etc.
• Evaluate
• review, monitor progress/complications etc
• Reflect

5
Case based learning
Reflect

• Case (CARE) reports are central to the learning
• Select case that represent experience gained
• learning objectives, practical prescribing,
  processes of care
• Summarising goes beyond passive clerking
• Case analysis, decisions reasoned action
• Evaluation of decisions, actions outcome
• Reflection on what one has learnt or should learn
• Cases should require 2-3 hours of background
  reading

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Choosing cases

• Learning objectives from 1st PETA meeting
• Direct Problems or cases to see
• Skills and cases used to demonstrate
• Knowledge (e.g. basic science) cases used to show
  learning (use Clinical science format if better)
• Use some cases to illustrate process of care
• E.g. long term monitoring of chronic disease
• Can sometimes use a case more than once for a new
  or very different problem
• Can adapt case format (with agreement) to suit
  placement circumstances

7
Case information

• History and examination only
• brief notes of the key features
• Positive negative aspects relevant to the
  problems / diagnoses
• Skill of summarising
• As you might do over the telephone to your future
  consultant
• Does not exclude a full clerking elsewhere

8
Analyse

• Clinical problems and list D-Diagnoses for each
• Investigations
• List the initial investigations
• List discriminating investigations in a realistic
  sequence
• Results
• List only key results that confirm diagnosis
• Remember to link any abnormal results with the
  implications for treatment.
• Provide a working diagnosis (or rarely diagnoses).

9
Rational Therapy

• Immediate therapy
• What procedures need to be performed?
• List the drugs prescribed ( link to formulary)
• the doses and route, and any interactions or
  precautions.
• Risks or adverse events to avoid
• Informing
• patient
• Who else?
• Where nursed, special instructions?
• Follow up
• handed over? discharge?
• Describe any long term therapy and communication

10
Evaluate

• Review the working diagnosis
• ? Is this correct in light of progress
• Future
• Monitoring the disease, progress and treatment?
• Best evidence practice
• Did the care follow a good practice and best
  evidence guideline?
• Adverse events
• Describe any problems or complications and
  explain why these might have occurred or how they
  could have been prevented (risk management)?
• List any other (e.g. family or social)
  implications?
• No use unless you read up about the case

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Reflection
Reflection
Describe - your thoughts on what you have
learned, where you have struggled, how you could
improve next time.

• Say how this case has helped you achieve your
  learning objectives?
• What new knowledge and skills have you learned
  from this experience?
• What should you learn more about?
• Have your professional attitudes been affected by
  this case? How will this influence your behaviour
  in the future?
• What have been your strengths in dealing with
  this case? Could you have done better?

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What goes wrong - the student?

• Superficial clerking, diagnosis and treatment
• Traditionalist view (record what seen without
  thinking), no summarising and analysis
• Often just a single diagnosis no problem list
• Thought process is lacking. Investigations lack
  focus
• No clear management plan or merely a prescription
• No attempt at evaluation, critical analysis of
  case or discussion of good evidence and bad
  practice
• Apparent no background reading
• The Student is unable to reflect on their
  learning
• The case experience fades and learning lost
• because the process was not followed in depth

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How to use the cases

• Regard the case as the frame upon which you will
  base your learning
• Avoid a simple observer approach
• Link to regular weekly reading
• If a case is a challenge
• Find people to talk with (e.g. SHOs / SPrs)
• Identify three cases for discussion at PETA
• Also identify additional cases that illustrate an
  ethical or risk management issue or good or bad
  practice
• Use critical incident forms for example
• Bring the cases to the fore for PETA meeting

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Two new formats

• Clinical Science/Therapeutic Reports
• Use to describe aspects of clinical physiology
  and treatment, or pathophysiology and treatment,
  or examples of pharmacology and therapeutics
• Replace 2 (sometimes up to 6) clinical case
  reports
• Should require up to 2 hours of learning
• Adverse Event/Critical Incident Report
• Use to document any adverse event or critical
  incidents including near misses that you
  encounter during your final year placements.
• From minor errors (omissions or commission) or
  serious events/incident.
• 2 per attachment
• Less work than a clinical case report
• Use in PETA discussions

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Clinical Science/Therapeutic Reports

• Alternative to clinical case reports
• Two sides of A4 only
• Use for at least two of your learning objectives
• Can use more in some SAMPs if better suited to
  this format of report
• Have a different format of sections
• Define the problem clinical significance
• Explain the clinical expression in terms of
  physiological and pathophysiological processes
• Describe the underlying pathological mechanisms
  and /or mechanisms of pharmacological
  intervention
• Describe Practical therapeutic options
  identifying benefits and risks
• Key Practice Points
• Reflection on your learning outcome meeting and
  identifying new learning objectives

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Adverse Event/Critical Incident Report

• A critical eye will disclose potential adverse
  events or critical incidents. Find these near
  misses and use these to learn how to avoid them
• Does not replace formal IR-1 forms but follows
  the same format
• Use as discussion in PETA meetings
• Categories
• Clinical Incident any occurrence related to a
  patients clinical management which did or could
  have resulted in harm to the patient, this
  includes near misses. Specific therapeutic errors
  are identified separately.
• Therapeutic error a specific medication error in
  prescribing that did or could have resulted in
  harm to the patient including near misses.
• Therapeutic adverse event a side effect or
  complication of treatment that may or may not
  have been the result of a prescribing error.
• Other incidents any near misses, equipment
  defects/failures, communication problems.
• Do not report on accidents, fire or security
  incidents unless they reflect poor care that
  could have harmed the patient.

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Adverse Event/Critical Incident Report

• Headings on form (one side A4)
• Define the event/incident
• Explain what happened, what was being done OR how
  it was recognised
• Outline extent of injury/ill health OR risk of
  injury/ill health
• Describe immediate action taken OR should be
  taken (treatment or change of treatment)
• Describe what action needs to be taken to prevent
  similar events re-occurring (refer to
  guidelines/standards)
• Reflection what have you learnt from this event,
  what is the impact on your practice
• Two forms per attachment
• Back of form has advice and examples

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How to prepare for PETA

• Number the case summaries (identify three)
• Explain how cases demonstrate your experience
• support the final PETA form conclusions. Where do
  the cases and formulary show your understanding
  of practical prescribing?
• Think about the cases
• Cases that show best evidence practice?
• Adverse events occurring in patient care?
• Recognised good and bad practice in professional
  behaviour or communication?
• Think about yourself
• Where have your skills advanced?
• Try and describe what you have learnt?
• In what ways has your attitude or professional
  confidence changed?

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Portfolio review 1st 20 min

• Collecting and analysing information.
• The key features important for diagnosis and
  management.
• Consider their analysis of the case.
• Question knowledge, interpretation of evidence,
  reasoning and judgement applied to clinical
  problem solving.
• Discuss the pathophysiology and how diagnoses are
  established?
• Ask on application of timely investigations and
  seek justification.
• Rationale Treatment
• Question planning and implementing treatment
  strategies and their practical application of
  skills.
• Address the risk-benefit of treatments and
  prescribing. Discuss what needs to be said to the
  patient or relatives
• Evaluation
• Are they able to discuss the outcome of a case?
  How was the final diagnosis established?
• Key feature of any good practice/best evidence
  guideline followed? What is the long-term
  prognosis and what follow up is required?
• Discuss patient education, illness prevention or
  risk identification. Was the student aware of
  any adverse events?

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Portfolio review 2nd 20 min

• Student selects a case that brings out ethical or
  legal issue.
• Were they involved with difficult ethical
  decisions? Death and sickness certifications and
  consent to therapy, post-mortem or research.
• Student identifies examples of good/poor practice
  or communication
• Difficult decisions, good application of the
  doctor-patient relationship or where they saw a
  poor example of professional practice or
  attitude. Honesty and respect for patients and
  their dignity. Explore what they understand by
  working as team and illustrate different kinds of
  responsibility.
• Clinical management
• Using cases see how the student understands
  efficient use of resources/investigation. Did the
  student encounter a case where they felt there
  was economic or practical constraint on provision
  of care?
• Critical awareness of their professional learning
  and practice.
• Reflection. Discuss educational skills and their
  ability to reflect on their experience. Can the
  student reflect on what they have done, what it
  stimulated them to learn and can they appreciate
  where they need to do more?